A Guide to Good Oral Health for Persons with Special Needs continued
Creating a Personal Oral Hygiene Program
This is a personal oral hygiene evaluation and program checklist that will help to evaluate the level of ability the person with special needs has in maintaining his or her oral hygiene. The following pagews will help to develop a regular and realistic individualized oral care program.
Take this form to your dentist or dental hygienist. He or she will complete it with you and talk with you about how best to help the person with special needs take care of his or her oral health.
Patient Skills Evaluation Checklist
Date: __________________________________________
Patient: ________________________________________
Caregiver: ______________________________________
1. Classification of Cleaning Skills (please check one):
[ ] Patient requires significant assistance
[ ] Patient has some dexterity but insufficient cleaning techniques
[ ] Patient can effectively brush with little assistance
[ ] Patient requires virtually no assistance 2. Current Patient Brushing Method (please check one):
[ ] Scrub Brush
[ ] Bass
[ ] Vibration
[ ] Circular
[ ] Roll
[ ] Electric
3. Toothpaste Usage Patient is using toothpaste
[ ] Yes
[ ] No
If yes, type of toothpaste used (e.g. tartar control)
__________________________________________
4. Rinse (please check one):
[ ] Patient rinses with chlorhexidine
[ ] Patient rinses with fluoride (please specify) _________________
[ ] Patient rinses with alternate rinse (please specify) ____________
[ ] Patient unable to rinse; caregiver uses swab technique with chlorhexidine
[ ] Patient is unable to rinse; caregiver uses swab technique with alternate rinse
(please specify):
_____________________________________________________
5. Floss (please check one):
[ ] Patient is able to floss
[ ] Patient is able to floss with finger holder
[ ] Patient is unable to floss; caregiver assistance needed
[ ] Patient is unable to floss; no flossing technique currently used
6. Fluoride
[ ] Liquid
[ ] Gel
Program Development Checklist
|
Regimen |
Patient |
Caregiver |
|
Toothbrushing
Monitor Activity
Toothbrush Modification
Electric Toothbrush
Toothpaste
Water
Fluoride Rinse
Fluoride Gel
Chlorhexidine Rinse
Chlorhexidine Brushing
Chlorhexidine Swab
Red Dye Program
Saliva Substitute
Floss
Reinforcers (e.g. food, TV, book)
Support
Arm
Head
Hand
Verbal Instructions
Position of Caregiver
Other:
Comments/Instructions: |
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